- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.65 / $199.62 / $217.42
| Facility | | $197.65 | $199.62 | $217.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.83 / $197.83 / $207.72
| Professional | | $197.83 | $197.83 | $207.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.83 / $217.61 / $296.75
| Facility | | $197.83 | $217.61 | $296.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.83 / $197.83 / $458.68
| Professional | | $197.83 | $197.83 | $458.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.63 / $194.08 / $197.83
| Facility | | $186.63 | $194.08 | $197.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.83 / $197.83 / $205.30
| Professional | | $197.83 | $197.83 | $205.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.05 / $511.05 / $511.05
| Facility | | $511.05 | $511.05 | $511.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.83 / $217.61 / $231.33
| Professional | | $197.83 | $217.61 | $231.33 |